Management of antithrombotic therapy after bleeding in patients with coronary artery disease and/or atrial fibrillation: expert consensus paper of the European Society of Cardiology Working Group on Thrombosis

Bleeding is a frequent complication of the management of patients with coronary artery disease (CAD), especially for those presenting with acute coronary syndromes (ACS) and undergoing percutaneous coronary intervention (PCI) while having persistent atrial fibrillation (AF). Randomised trials have shown a 1-8% 30-day risk of major bleeding in ACS patients,1-5 and 2-5% per year in patients with AF treated with oral anticoagulants.6 Observational studies suggest that this risk is even higher.7 Major bleeding has important clinical implications with a subsequent increase in both short- and long-term mortality.7-13 Minor bleeding may also have prognostic impact on overall outcome and especially on patient´s compliance.14 Several mechanisms have been put forward to explain the relationship between bleeding and increased mortality (Figure 1). The overlap in risk factors for bleeding and ischaemic events means that patients who are more likely to suffer from bleeding complications of antithrombotic therapy also tend to be at higher risk of thrombotic events. Bleeding may lead to discontinuation of antithrombotic drugs and subsequent thrombotic events due to the progressive recovery of platelet function and coagulation activity.15, 16 In addition, bleeeding may provoke prothrombotic responses beyond those related to discontinuation of antithrombotic drugs.17, 18 Clearly, decisions about how and when to restart antithrombotic therapy after bleeding are critical in optimally balancing the risks of further bleeding versus potentially fatal thrombotic events.